3867 (12/2016)
Tips For Claim Submission
• An eligible dependent is defined as a spouse, qualifying child, or
qualifying relative.
• A qualifying child is defined as a tax dependent child up to age
26 or any age if permanently disabled.
• A qualifying relative is someone who resides with you for
more than half of the year.
• Qualifying children and relatives must not provide more than
half of his/her own support.
• For a complete list of eligible expenses specific to your plan,
log in to your account at takecareWageWorks.com and select
“Eligible Expense” from the left side of the screen. Only submit
claims for eligible expenses.
• A letter of medical necessity is required for any expense listed
as “Yes (Letter)” on the eligible expense list to establish medical
necessity. Cosmetic surgery or procedures, e.g., teeth whitening,
are not eligible expenses unless deemed as medically neces-
sary by a licensed physician. A letter of medical necessity form
can be obtained at:
http://www.takecareWageWorks.com/ee/ee_fac.html.
Tip for Over-the-Counter Expenses
• A prescription is required for any over-the-counter expense
listed as “Yes (Rx)” on the eligible expense list. As a result
of the Health Care Reform Law, in addition to the required
detailed receipt, an actual prescription written by a doctor (on
a prescription pad or form) dated on or before the date the
expense was incurred is required to verify that the over-the-
counter medicine is prescribed for a known medical condition.
Tips For Documentation
• Ensure that the documentation is legible.
• Cancelled or copies of checks and credit card receipts do not
contain all 6 required pieces of information needed to approve
your expense, and are not acceptable for submission.
• Explanation of Benefits (EOBs) are recommended, especially if
your insurance covered a portion of the expense.
• The use of a highlighter causes items to not be legible on the
documentation; highlighter use is not recommended.
• Send only photocopies of your claim form and documentation—
keep the originals for your records if submitting via US Mail.
• Your provider may sign the form confirming the date of services,
charges, and other service or product information in lieu of
providing separate documentation or other proof of service.
Tips For Faxing
• Do not use a cover page when faxing the claim form and
documentation.
• Submit only claims for your own account.
Tips for Viewing Claim Status
• Please allow 2 business days from receipt of your claim for
processing.
• You will be notified via email of the status of your claim if we
have a valid email address on file (to update your email address,
please log into your account at takecareWageWorks.com and
select “Profile” in the upper right corner of the screen).
HEALTHCARE ACCOUNT
How to File a Claim for Approval
Instructions to fill out this form:
• Complete ALL account holder information.
• Provide your employer name without
abbreviation.
• Use your documentation to complete
each section of the form, including the
following:
Provider Name
Service Date(s)
Patient Name and Relationship
to Account Holder
Type of Service
Patient Responsibility
Provider Signature is
not required
,
but can replace need for other proof
of service
SM I T H JOHN
JONES GRA PH I CS
5421
10063
Mercy Hospital
Dr. Mark Johnson, M.D.
Mercy Pharmacy
010515
010515
011415
011415
John Smith
Mary Smith
2 5 0 0
1 0 70
Claim Filing Options:
• File claim online: Log in to your account at takecarewageworks.com to submit your claim electronically.
• File claim via fax, email, or mail: Claim details may be entered online and a completed form may be printed and faxed or
mailed with documentation. Fax: 877-782-8889, US Mail: CLAIMS ADMINISTRATOR, PO Box 14054, Lexington, KY, 40512,
Email: claims@takecareclaims.com
